Treatment of patients with type 2 diabetes: from text book therapy to personalized medicine
|
|
- Megan Daniel
- 8 years ago
- Views:
Transcription
1 1 Treatment of patients with type 2 diabetes: from text book therapy to personalized medicine BruceH H.R. Wolffenbuttel, MDPhD Professor of Endocrinology & Metabolism University Medical Center Groningen The Netherlands e mail: bwo@umcg.nl 2 BHRW2012 1
2 3 The UMCG from the air Diabetes Center Outpatient Endocrinology dept beds 8500 employees 4 Type 2 diabetes is a complex disease BHRW2012 2
3 Diabetes can ruin your life completely 5 Most important cause of blindness in adults 2 6x increased risk for coronary heart disease and stroke Amputations 15x as often Most important cause of kidney failure and dialysis 12 American Diabetes Association, Vital Statistics 1996 Type 2 diabetes: a complicated way to get cardiovascular disease and die young 6 Don't forget depression BHRW2012 3
4 Type 2 diabetes: the challenge 7 glucose lipids blood pressure obesity diet normal living quality of life 8 Strict glycaemic control with sulphonylurea* or insulin reduces complications! * chlorpropamide, glibenclamide!! < P=0.052 Reduction (%) intensive (HbA1c 7.0%) vs conventional (HbA1c 7.9%) BHRW2012 4
5 UKPDS epidemiologic study: better glycaemic control means fewer complications 9 Complications % HbA1c = 33% eyes, kidney % heart/bloodvessels ,0 7,0 8,0 9,0 10,0 HbA1c (%) ADA/EASD goals HbA1c < 7.0% UKPDS 1998 UKPDS 10 year follow up glucose blood pressure 10 The effects of BG control do seem to persist, those of BP control not Holman et al. NEJM 2009 BHRW2012 5
6 UKPDS longest study, but still controversial 11 Proportion of patients with ev vents Conventional (411) Intensive (951) Metformin (342) M v C p= M v I p= recently diagnosed diabetes and obesity Years from randomisation Question 1 12 Diabetes treatment may become very complex. How many different drugs is an average person with type 2 diabetes usually taking? BHRW2012 6
7 Multifactorial therapy has enormous consequences 13 An average type 2 diabetes patient will use: one or two drugs lowering blood glucose, 2 3 eventually insulin cholesterol lowering treatment ('statin for all') blood pressure lowering treatment: ACE inhibitor + at least one other drug probably aspirin any other drug related to co morbidity (CVD, COPD, arthrosis, osteoporosis) ? 6 9! Please do not be fooled by your patients! 14 How many patients with type 2 diabetes are really taking the prescribed medication? Type of drug % Adherent Oral BG lowering agents 50.0 Antihypertensive drugs 50.0 Lipid lowering drugs 69.7 Platelet aggregation inhibitors 77.5 All medications 35.4 Mateo JF et al. Int J Clin Pract 2006; 60: BHRW2012 7
8 15 Depression may interfere with optimal type 2 diabetes treatment Depression has a complex of complaints 16 Depressive symptoms Loss of pleasure or interest in other people Feelings of guilt or low selfesteem Pessimism linked to feelings of disease, sometimes suicidal ideas Significant loss of body weight or sometimes increase Sleeplessness or increased need for sleep Agitation, slow Fatigue, loss of energy Disturbed attention, memory BHRW2012 8
9 Depression will lead to poor self management 17 Less physical exercise Less dietary adherence Less compliant with taking medication Skip self monitoring of blood glucose and adjustment of insulin More difficult to stop smoking Skipping doctor's appointments Prevalence of depression as co morbidity 18 Depression Depressive symptoms Diabetes 11 % 31 % Cerebrovascular disease Acute heart disease % 33 % 20 % 31 % It is important to recognize depression, as this may strongly interfere with treatment! Van der Feltz Cornelis, 2006 BHRW2012 9
10 Screening for depression 19 Look for signs of depression poor control dissatisfied missing appointments emotional eaters Take depression questionnaire: BDI: Beck depression inventory PHQ9: Patient Health Questionnaire Psychological support Medication 20 Current trend: increasing focus on treatments which do NOT cause hypoglycaemia BHRW
11 Glycaemic targets in guidelines 21 ADA / EASD For microvascular disease prevention, HbA1c goal for adults in general is < 7% For selected patients, providers may suggest even lower HbA1c goals, if this can be achieved without significant hypoglycaemia Less stringent control may be appropriate for patients with a history of severe hypoglycaemia, limited life expectancy, advanced complications Diabetes Care 2009; 32 (suppl.1): S6 12; IDF Global Guideline for Type 2 Diabetes Macrovascular outcomes in ACCORD and ADVANCE: no difference between 'standard' and 'intensive' 22 BHRW
12 ACCORD showed high incidence of severe hypo 23 p<0.001 intensive control arm stopped prematurely because of increased C.V. events Also cross sectional studies show increased all cause mortality in those with lowest HbA1c 24 oral combination insulin based therapies Primary care database on diabetes treatment in England: 1. Those on insulin had more c.v. disease & renal insufficiency 2. With very low HbA1c, we observe an increase in mortality Currie CJ, et al. Lancet 2010; 375: BHRW
13 Same HbA1c, different numbers of hypoglycaemia 25 Patient 1: type 2 diabetes for 5 years metformin 2dd 1000 mg, sitagliptin 100mg HbA1c 6.5% no hypoglycaemia Patient 2: type 2 diabetes for 8 years metformin 2dd 1000 mg, glargin 44 U at bedtime HbA1c 6.5% 3 mild hypo's per week 1 severe hypoglycaemia per person per year We know a lot about metabolic effects of various diabetes treatments, but almost nothing about their long term effects!! 26 Type 2 diabetes treatment is difficult BHRW
14 There are many choices in the treatment of type 2 diabetes 27 second line drug features Lifestyle intervention (healthy food, weight reduction, physical activity) Metformin (metabolic control, less c.v. events, no hypoglycaemia, no weight increase Sulphonylurea Glinides Thiazolidines α GIucosidase inh. DPP 4 inhibitors GLP1 agonists Insulin hypo, weight gain hypo, safe in renal insuff. edema, c.v.d., bladder pp. BG, GI side effects no hypo, neutral weight injections, weight loss injections, weight gain, BG measurements Progression of type 2 diabetes makes treatment choices / regimens more complicated 28 Lifestyle Metformin Combi tablets GLP1 Simple insulin Complex insulin BHRW
15 29 Each treatment regimen should take into account lifestyle and other activities * active elderly * cab driver * unemployed * house wife * researcher * secretary The case of mr. A., 44 years 30 Type 2 diabetes Cab driver * Weight 90 kg BMI 30 kg/m2 Metformin 2g Simvastatin 40mg Lisinopril 20mg Goal: improving glycaemic control without hypoglycaemia Start sitagliptin 100 mg Weight 88 kg BMI 29.3 * cab drivers do not want to become hypoglycaemic BHRW
16 The case of mr. D., 49 years 31 Type 2 diabetes since 2005 Unemployed, sedentary lifestyle, arthrosis of the knees BMI 39.7 kg/m : failure of therapy on glimepiride 4 mg + metformin 1000 mg tid Goal: improving glycaemic control & weight reduction Starting Exenatide 2 dd 5 10 mcg Was able to stop glimepiride No hypoglycaemia Reduction of weight 4 kg, BMI now 38.4 kg/m2 Question 2 32 For a patient with type 2 diabetes, intolerant to metformin, failing gliclazide + sitagliptin, HbA1c 7.9%, BMI 30 kg/m2, I would prescribe: 1. a GLP1 agonist like exenatide 2. basal insulin (glargine) 3. twice daily premix insulin (LisPro mix 25) 4. multipledailyinsulin insulin injections BHRW
17 The case of mrs. E., 59 years 33 Type 2 diabetes Weight 90 kg BMI 30 kg/m2 intolerant to metformin gliclazide + sitagliptin simvastatin normal blood pressure Goal: improving control but wants to loose weight start of exenatide bid, pays for it herself 100 Euro per month Weight 75 kg (BMI 25) Insulin or GLP1 agonist as a first step after failure on oral agents? 34 Exenatide 2 dd 5 mcg 2 dd 10 mcg 501 patients DM2 age years HbA 1c 7 11% (SU+MF) BMI kg/m 2 Randomized study 13 countries Time (weeks) Novomix 30 2 dd sc Nauck M., et al. Diabetologia 2007 BHRW
18 Exenatide: lower body weight and postprandial BG 35 Exenatide Difference 5.4 kg Insulin 36 Type 2 diabetes is a progressive disease eventually all patients need insulin treatment BHRW
19 Are combinations of insulin plus GLP1 agonist feasible and / or approved 37 Combination of GLP1 agonist and insulin may limit weight increase due to insulin use and appetite stimulation Possibly there is better postprandial control by GLP1 effect on insulin secretion and on stomach emptying Exenatide is approved by EMA & FDA as adjunct to longacting insulin (Lantus) A study on exenatide vs. humalog on top of insulin glargine is still ongoing, the results expected beginning of 2013 Combination of GLP1 agonist and basal bolus insulin therapy currently not approved Progression of type 2 diabetes makes treatment choices / regimens more complicated 38 Failure on oral agents (OA) MF+OA+ GLP1ag MF+OA+ basal insulin MF+PreMix Insulin MF+GLP1ag+ basal insulin MF+GLP1ag +BBT (?) Not approved yet MF+ BasalBolus BHRW
20 39 Address patient reluctance: patients who perform self monitoring of blood glucose will more rapidly switch from tablets to insulin What do we want to achieve with insulin therapy? 40 Reduce hyperglycaemic complaints Achieve (near) normoglycaemia: BG between 5 and 8 mmol/l Prevent complications Avoid hypoglycaemia, especially in the elderly Can be easily adjusted in specific circumstances driving car, eating out, on holidays Canbe easilyadministeredby administered nurse ifinnursing in nursing home BHRW
21 What is success? 41 For the doctor: treatment is simple to explain is based on evidence normalizes blood glucose leads to beautiful HbA1c* prevents complications gives no hypoglycaemia gives no increase body weight What is success? 42 For the patient: it is a simple treatment has no side effects I can eat and drink all no injections please, and no fingerpricks I don t know what hypo is, but surely do not want it I still want to visit my grandchildren my neighbour went blind after starting insulin 1. Bring some simplicity 2. Discuss misconceptions and misbelieves BHRW
22 Summary of factors for success in insulin therapy 43 Education: discuss expectations discuss 'insulin resistance' and teachsmbg discuss weight gain and hypoglycaemia (and how to avoid it) Tailoring: choose two or three starter regimens, gain experience with them, and adjust if needed encourage insulin regimen which 'fits' the patient and can be adjusted to long term goals and lifestyle Insulin treatment options in type 2 diabetes 44 Prandial / Intensified insulin therapy Conventional insulin therapy Basal insulin therapy Short acting insulin Usually 2 injections long acting / NPH insulin (analog) prandially + mix of short acting insulin (analog) +/ oral agents long acting / NPH insulin and long acting insulin BHRW
23 45 What kind of treatments is Europe giving when starting insulin therapy in type 2 diabetes? Results from the INSTIGATE study 100 % of patients basal only premixed only short acting only basal-bolus other 0 Germany France UK Greece Spain Smith H, et al. Diabetologia 2008; 51 (suppl. 1): S The case of mr. G., 40 years Academic researcher Daughter with type 1 diabetes Working to loose weight But: Type 2 diabetes, recently diagnosed Weight 85 kg BMI 27.5 kg/m 2 metformin 3x1000 mg start of glargin 8U at bedtime uptitrated t till 24 U metformin 2 dd 1000 mg hrs BHRW
24 The case of mrs. U., 68 years 47 In 2008 partial resection of pancreas, benign Post.operative hyperglycaemia, started with insulin Uses LisPro Mix 25, 22U before breakfast, 10U before dinner Also perindopril, thiazide, simvastatin, acetylsalicylic acid (after a small stroke) Leads a stable but active life, lives 5 6 months per year in Thailand Does not want to go to multiple injections! Occasionalhypoglycaemia, with goodawareness Self monitoring: see next slide The case of mrs. U., 68 years 48 7 am 11 am 3 pm 8pm LisPro Mix U before breakfast 10 U before evening meal BHRW
25 Question 3 49 You have a patient with type 2 diabetes, BMI 29, who was failing on metformin and a sulphonylurea. He started insulin glargin once daily at bedtime. He is now in stable control, with FBG 5 7 mmol/l, HbA1c fell from 8 to 6.5%. How long will it take (on average) before his HbA1c again is > 7.0%? months months months 4. longer than 24 months LisPro Mix 25 gives better glycaemic control than longacting analogue Glargine* (DURABLE study) 50 change H ba1c (%) 0,0-0,5-1,0, -1,5-2,0 1,8 1,7 p<0.01 LM25 Glargine episode e/pt/yr p< ,0 23,1 LM25 Glargine % with HbA1c < 7.0% p< ,5 40,3 LM25 Glargine severe hypo (n n) p= LM25 Glargine * after 24 weeks of study adapted from: Wolffenbuttel et al. Diabetologia 2008 (A959) BHRW
26 Long term efficacy of insulin regimens is limited (DURABLE study) 51 On average, it will take 14 months before HbA1c again rises to > 7.0% LM25 LisPro Mix 25 Glargine Probability p=0.04 between treatment difference Months of Maintaining HbA 1c Goal < 7.0% Wolffenbuttel BHR, et al. EASD 2010 The case of mrs. D., 64 years 52 Still active, works as secretary In 1999 type 2 DM, glibenclamide 3dd 5 mg, metformin 3dd500mg (diarrhoeawith higher dose) Insulin since 2005, because of tablet failure Started with Humalog Mix 25, U Occasional hypoglycaemia with sports, also wanted to loose weight. Therefore went to NPH insulin and LisPro Currently using 12 6/8 6/8U LisPro, 24U NPH; adjusts LisPro according to BG values and meal size Weight 83 kg, height 1.68 m, weight before insulin was 80 kg. HbA1c % at present BHRW
27 The case of mrs. D., 64 years : Type 2 diabetes, max. oral agents Weight 80 kg, BMI 27.5 kg/m2 HbA1c 8.3 % 2012 started with NPH 8U daily + Lispro before meals 2012: NPH uptitrated to 24 U LisPro 12 6/8 6/8 U Weight 83 kg, HbA1c 6.6% 54 The postprandial state in type 2 diabetes (study design) Pre meal insulin lispro MM 50/50 + metformin LM bid + metformin insulin glargin + metformin Sub group (n=46) of 315 patients randomized Test meal* Test meal* 6 ±2 0 4 Week * McDonald s breakfast [fat 39 g, CHO 78 g, protein 24 g, kcal 750] adapted from: Tan et al. Diabetologia 2006: Abstract 0989 BHRW
28 Better postprandial blood glucose profiles with higher percentage of fast acting insulin analogue insulin glargine + MF * p<0.05 BG (mmol/l ) * * * * * 4 insulin lispro + NPL mixture + MF Time (hours) 46 patients with type 2 diabetes taking a McDonald s breakfast [fat 39 g, CHO 78 g, protein 24 g, kcal 750] adapted from: Tan et al. Diabetologia 2006: Abstract 0989 hs CRP follows postprandial BG excursions 56 hs-crp (ng/m l) 4000 * * p<0.05 * MM+MF 3000 * G+MF Time (hours) breakfast adapted from: Tan et al. Diabetologia 2006: Abstract 0989 BHRW
29 Higher PPBG coincide with higher postprandial levels of IL6 and TNFα p< p=0.007 p= LisPro Glargine Blood glucose IL6 TNFα ( mmol*min/5) (pg/ml*min) (pg/10ml*min) adapted from: Tan MH, et al. Diabetes 2007: 56 (suppl.1): A174 Are ultrafast acting insulin analogues better than regular insulin in type 2 diabetes? 58 Injection directly before a meal Possible to inject after a meal when meal size is unknown Faster normalization when blood glucose is too high Better control of postprandial blood glucose * Smaller postprandial increase of inflammation markers * Lower incidence of nocturnal hypoglycaemia Overall similar HbA1c Very limited data on effects of complications Price??? In The Netherlands, 95% of fast acting insulin is an insulin analogue (aspart, lispro) BHRW
30 59 There are only few studies on the long term effects of type 2 diabetes therapy 4T: three year effects of 3 treatment regimens 60 82% need to add fast acting insulin Holman R, et al. NEJM 2009 BHRW
31 More intensive insulin treatment associated with higher body weight, insulin dose and hypoglycaemia 61 Change in BW (kg) Insulin dose (U) Hypo & Basal Biphasic Prandial +1.9 ± (28 to 72) ±4.0 * 48 (30 to 71) 5.7 * +5.7 ±4.6 * # 56 (34 to 78) 12.0 * # & Grade 2 events/patient/year / N Engl J Med 2007; 357: Specific situations BHRW
32 Type 2 diabetic and wanting to become pregnant 63 Type 2 diabetes increasingly is occurring in younger people Many of them want to have children Poorer glycaemic control is associated with higher risk of congenital malformations and eclampsia Type 2 diabetic and wanting to become pregnant 64 Pregnancy in type diabetes means 'planning': education about all aspects of a safe pregnancy risk of eclampsia and premature delivery switch from oral agents to insulin multiple injection regimen to be preferred, incl. NPH insulin and fast acting insulin analogue (LisPro, Aspart) long acting analogues not approved for pregnancy try to achieve HbA1c 65%or 6.5% below for a number of months before becoming pregnant start with folic acid supplementation BHRW
33 65 Ramadan (July 20 August 18, 2012!) 66 People with diabetes are allowed not to fast Nevertheless, many wíll participate fully (pride, peer pressure, etc.) Ramadan means breakfast before sunrise (which is early in July, approx am!!), and dinner after sunset (10 pm!!) Dinner usually large and rich in carbohydrates Dinner usually large and rich in carbohydrates Goal is to maintain reasonable blood sugar levels without hypoglycaemia BHRW
34 Ramadan (July 20 August 18, 2012!) Some simple rules for adjustment of medication 67 Oral agents: Tolbutamide, gliclazide & glibenclamide: morning half dose, evening before dinner full dose Glimepiride: take tablets in evening Insulin: Once daily long acting: Take at / with evening meal Twice daily premix insulin (like LisPro Mix25): Fast acting in morning, premix at dinner Metformin: morning half dose, evening full dose Multiple injections: Fast acting in morning and evening, long acting at bedtime 68 Summary BHRW
35 HbA1c target depending on risk evaluation 69 Young < 40 years Middle aged years Elderly > 70 years Complications No Yes No Yes No Yes <6.0 <6.5 <7.0 < Aim for more strict control when without complications 2. Risk of hypoglycaemia varies with type of drugs 3. Less strict control in elderly, those with complications or reduced life expectancy Summary of effects of insulin regimens 70 Prandial / Intensified (basal bolus) Conventional (premixed) Basal (NPH / long acting) HbA1c (if OA s continued) (30 50% HbA1c 7.0%) PPBG control better better worse regimen difficult slightly difficult easy, continue OA s hypoglycaemia +++ weight gain +++ complications? ++ ++? + +? BHRW
36 Summary of insulin therapy 71 Intensive BG lowering Fast actingacting analogs Combination with metformin Intensive insulin treatment Simplestarter insulin regimen benefit microvascular; dangerous in long term diabetics & w. severe CVD better ppbgcontrolthanregularinsulin than regular insulin, may reduce c.v. complications reduces insulin dose and mitigates weight increase more hypoglycaemia, weight gain needs intensification within 14 to 18 months, because HbA1c increase Take home messages 72 Depression may interfere with optimal diabetes therapy Currently there is increasing focus on treatments which do not cause hypoglycaemia, but they are more expensive There are only few studies on the long term effects of insulin therapy (in fact on effects of all treatments) Situations like pregnancy & ramadan ask a lot of effort from patient and doctor Diabetes therapy = personalized medicine BHRW
When and how to start insulin: strategies for success in type 2 diabetes
1 When and how to start insulin: strategies for success in type diabetes Treatment of type diabetes in 199: with each step treatment gets more complex Bruce H.R. Wolffenbuttel, MD PhD Professor of Endocrinology
More informationInsulin switch & Algorithms Rotorua GP CME June 2011. Kingsley Nirmalaraj FRACP Endocrinologist BOPDHB
Insulin switch & Algorithms Rotorua GP CME June 2011 Kingsley Nirmalaraj FRACP Endocrinologist BOPDHB Goal of workshop Insulin switching make the necessary move Ensure participants are confident with Recognising
More informationWorkshop A Tara Kadis
Workshop A Tara Kadis Considerations/barriers in decision making about insulin verses GLP-1 use in people with type 2 diabetes Which Insulin regimes should we consider? Diabetes is a progressive multi-system
More informationINSULIN TREATMENT FOR TYPE 2 DIABETES MANAGEMENT
INSULIN TREATMENT FOR TYPE 2 DIABETES MANAGEMENT APIRADEE SRIWIJITKAMOL DIVISION OF ENDOCRINOLOGY AND METABOLISM DEPARTMENT OF MEDICINE FACULTY OF MEDICINE SIRIRAJ HOSPITOL QUESTION 1 1. ท านเคยเป นแพทย
More informationSHORT CLINICAL GUIDELINE SCOPE
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SHORT CLINICAL GUIDELINE SCOPE 1 Guideline title Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes 1.1 Short title Type 2
More informationThe basal plus strategy. Denis Raccah, MD, PhD Professor of Medicine University Hospital Sainte Marguerite Marseille FRANCE
The basal plus strategy Denis Raccah, MD, PhD Professor of Medicine University Hospital Sainte Marguerite Marseille FRANCE ADA/EASD guidelines recommend use of basal insulin as early as the second step
More informationTherapy Insulin Practical guide to Health Care Providers Quick Reference F Diabetes Mellitus in Type 2
Ministry of Health, Malaysia 2010 First published March 2011 Perkhidmatan Diabetes dan Endokrinologi Kementerian Kesihatan Malaysia Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus Quick
More informationInsulin Therapy In Type 2 DM. Sources of support. Agenda. Michael Fischer, M.D., M.S. The underuse of insulin Insulin definition and types
Insulin Therapy In Type 2 DM Michael Fischer, M.D., M.S. Sources of support NaRCAD is supported by a grant from the Agency for Healthcare Research and Quality My current research projects are funded by
More informationTYPE 2 DIABETES SEQUENTIAL INSULIN STRATEGIES
TYPE 2 DIABETES SEQUENTIAL INSULIN STRATEGIES Non-insulin regimes Basal insulin only (usually with oral agents) Number of injections 1 Regimen complexity Low Basal insulin +1 meal-time rapidacting insulin
More informationInsulin use in Type 2 Diabetes. Dr Rick Cutfield. Why? When? How?
Insulin use in Type 2 Diabetes Dr Rick Cutfield Why? When? How? 1 Conflict of Interest I have been on advisory boards or had speaker fees from the following pharmaceutical companies: - Eli Lilly - Novo
More informationDiabetes Mellitus 1. Chapter 43. Diabetes Mellitus, Self-Assessment Questions
Diabetes Mellitus 1 Chapter 43. Diabetes Mellitus, Self-Assessment Questions 1. A 46-year-old man presents for his annual physical. He states that he has been going to the bathroom more frequently than
More informationType 2 Diabetes: When to Initiate And Intensify Insulin Therapy. Julie Bate on behalf of: Dr John Wilson Endocrinologist Capital and Coast DHB
Type 2 Diabetes: When to Initiate And Intensify Insulin Therapy Julie Bate on behalf of: Dr John Wilson Endocrinologist Capital and Coast DHB Declarations I have received travel funding and speaker fees
More informationINSULIN INTENSIFICATION: Taking Care to the Next Level
INSULIN INTENSIFICATION: Taking Care to the Next Level By J. Robin Conway M.D., Diabetes Clinic, Smiths Falls, ON www.diabetesclinic.ca Type 2 Diabetes is an increasing problem in our society, due largely
More informationDiabetes: When To Treat With Insulin and Treatment Goals
Diabetes: When To Treat With Insulin and Treatment Goals Lanita. S. White, Pharm.D. Director, UAMS 12 th Street Health and Wellness Center Assistant Professor of Pharmacy Practice, UAMS College of Pharmacy
More informationInsulin therapy in various type 1 diabetes patients workshop
Insulin therapy in various type 1 diabetes patients workshop Bruce H.R. Wolffenbuttel, MD PhD Dept of Endocrinology, UMC Groningen website: www.umcg.net & www.gmed.nl Twitter: @bhrw Case no. 1 Male of
More informationUser guide Basal-bolus Insulin Dosing Chart: Adult
Contacts and further information Local contact Clinical pharmacy or visiting pharmacy Diabetes education service Director of Medical Services Visiting or local endocrinologist or diabetes physician For
More informationInitiating & titrating insulin & switching in General Practice Workshop 1
Initiating & titrating insulin & switching in General Practice Workshop 1 Workshop goal To make participants comfortable in the timely initiation and titration of insulin Progression of Type 2 Diabetes
More informationTrends in Prescribing of Drugs for Type 2 Diabetes in General Practice in England (Chart 1) Other intermediate and long-acting insulins
Type 2 Diabetes Type 2 diabetes is the most common form of diabetes, accounting for 90 95% of cases. 1 Charts 1 and 2 reflect the effect of increasing prevalence on prescribing and costs of products used
More informationInsulin or GLP1 How to make this choice in Practice. Tara Kadis Lead Nurse - Diabetes & Endocrinology Mid Yorkshire Hospitals NHS Trust
Insulin or GLP1 How to make this choice in Practice Tara Kadis Lead Nurse - Diabetes & Endocrinology Mid Yorkshire Hospitals NHS Trust Workshop Over View Considerations/barriers to treatments in type 2
More informationInsulin myths and facts
london medicines evaluation network Insulin myths and facts Statement 1 Insulin is the last resort for patients with Type 2 diabetes After initial metformin and sulfonylurea therapy, NICE and SIGN suggest
More informationIntensifying Insulin Therapy
Intensifying Insulin Therapy Rick Hess, PharmD, CDE, BC-ADM Associate Professor Gatton College of Pharmacy, Department of Pharmacy Practice East Tennessee State University Johnson City, Tennessee Learning
More informationManaging diabetes in the post-guideline world. Dr Helen Snell Nurse Practitioner PhD, FCNA(NZ)
Managing diabetes in the post-guideline world Dr Helen Snell Nurse Practitioner PhD, FCNA(NZ) Overview Pathogenesis of T2DM Aims of treatment The place of glycaemic control Strategies to improve glycaemic
More informationStarting Insulin Sooner Than Later
Starting Insulin Sooner Than Later Rotorua GP Insulin Seminar 13 June 2014 Kingsley Nirmalaraj MBBS, FRACP, FACE Consultant Endocrinologist and Physician Tauranga Hospital/ Bay Endocrinology Ltd Declaration
More informationInsulin Initiation and Intensification
Insulin Initiation and Intensification ANDREW S. RHINEHART, MD, FACP, CDE MEDICAL DIRECTOR AND DIABETOLOGIST JOHNSTON MEMORIAL DIABETES CARE CENTER Objectives Understand the pharmacodynamics and pharmacokinetics
More informationBritni Hebert, MD PGY-1
Britni Hebert, MD PGY-1 Importance of Diabetes treatment Types of treatment Comparison of treatment/article Review Summary Example cases 1 out of 13 Americans have diabetes Complications include blindness,
More informationTake a moment Confer with your neighbour And try to solve the following word picture puzzle slides.
Take a moment Confer with your neighbour And try to solve the following word picture puzzle slides. Example: = Head Over Heels Take a moment Confer with your neighbour And try to solve the following word
More informationIntensive Insulin Therapy in Diabetes Management
Intensive Insulin Therapy in Diabetes Management Lillian F. Lien, MD Medical Director, Duke Inpatient Diabetes Management Assistant Professor of Medicine Division of Endocrinology, Metabolism, & Nutrition
More informationGlycaemic Control in Adults with Type 1 Diabetes
Glycaemic Control in Adults with Type 1 Diabetes Aim(s) and objective(s) This document aims to provide guidance on good clinical practice in managing glycaemic control in adult patients with Type 1 Diabetes
More informationINSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT?
INSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT? MARTHA M. BRINSKO, MSN, ANP-BC CHARLOTTE COMMUNITY HEALTH CLINIC CHARLOTTE, NC Diagnosed and undiagnosed diabetes in the United
More informationType 2 Diabetes. Aims and Objectives. What did you consider? Case Study One: Miss S. Which to choose?!?! Modes of Action
Aims and Objectives This session will outline the increasing complexities of diabetes care, and the factors that differentiate the combinations of therapy, allowing individualisation of diabetes treatment.
More informationHarmony Clinical Trial Medical Media Factsheet
Overview Harmony is the global Phase III clinical trial program for Tanzeum (albiglutide), a product developed by GSK for the treatment of type 2 diabetes. The comprehensive program comprised eight individual
More informationINPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco
INPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco CLINICAL RECOGNITION Background: Appropriate inpatient glycemic
More informationInsulin/Diabetes Calculations
Insulin/Diabetes Calculations Dr. Aipoalani St Lukes Endocrinology Goals Describe various calculations for insulin dosing Understand importance of the total daily dose (TDD) of insulin Be able to calculate
More informationAlgorithms for Glycemic Management of Type 2 Diabetes
KENTUCKY DIABETES NETWORK, INC. Algorithms for Glycemic Management of Type 2 Diabetes The Diabetes Care Algorithms for Type 2 Diabetes included within this document are taken from the American Association
More informationCLASS OBJECTIVES. Describe the history of insulin discovery List types of insulin Define indications and dosages Review case studies
Insulins CLASS OBJECTIVES Describe the history of insulin discovery List types of insulin Define indications and dosages Review case studies INVENTION OF INSULIN 1921 The first stills used to make insulin
More informationLead Clinician(S) (DATE) Approved by Diabetes Directorate on: Approved by Medicines Safety Group on: This guideline should not be used after end of:
Guideline for members of the diabetes team and dietetic department for advising on insulin dose adjustment and teaching the skills of insulin dose adjustment to adults with type 1 or type 2 diabetes mellitus
More informationDiabetes Mellitus. Melissa Meredith M.D. Diabetes Mellitus
Melissa Meredith M.D. Diabetes mellitus is a group of metabolic diseases characterized by high blood glucose resulting from defects in insulin secretion, insulin action, or both Diabetes is a chronic,
More informationNCT00272090. sanofi-aventis HOE901_3507. insulin glargine
These results are supplied for informational purposes only. Prescribing decisions should be made based on the approved package insert in the country of prescription Sponsor/company: Generic drug name:
More informationDavid Shu, MD, FRCPC Endocrinology, Royal Columbian Hospital October 8 th, 2010
David Shu, MD, FRCPC Endocrinology, Royal Columbian Hospital October 8 th, 2010 Objectives At the end of the talk, the participants will be able to: 1. Identify the increasing prevalence of type 2 diabetes
More information4. Does your PCT provide structured education programmes for people with type 2 diabetes?
PCT Prescribing Report Drugs used in Type 2 Diabetes Discussion Points 1. Does your PCT have a strategy for prevention of type 2 diabetes? Does your PCT provide the sort of intensive multifactorial lifestyle
More informationCochrane Quality and Productivity topics
Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus NICE has developed the Cochrane Quality and Productivity (QP) topics to help the NHS identify practices
More informationIMPROVED METABOLIC CONTROL WITH A FAVORABLE WEIGHT PROFILE IN PATIENTS WITH TYPE 2 DIABETES TREATED WITH INSULIN GLARGINE (LANTUS ) IN CLINICAL
464 IMPROVED METABOLIC CONTROL WITH A FAVORABLE WEIGHT PROFILE IN PATIENTS WITH TYPE 2 DIABETES TREATED WITH INSULIN GLARGINE (LANTUS ) IN CLINICAL PRACTICE STEPHAN A SCHREIBER AND ANIKA RUßMAN ABSTRACT
More informationThis information explains the advice about type 2 diabetes in adults that is set out in NICE guideline NG28.
Information for the public Published: 2 December 2015 nice.org.uk About this information NICE guidelines provide advice on the care and support that should be offered to people who use health and care
More informationDM Management in Elderly- What are the glucose targets?
DM Management in Elderly- What are the glucose targets? AFSHAN ZAHEDI, BASC, MD, FRCP(C) ENDOCRINOLOGY WOMEN S COLLEGE HOSPITAL ASSISTANT PROFESSOR OF MEDICINE UNIVERSITY OF TORONTO NOVEMBER 2, 2011 Disclosures
More informationTYPE 2 DIABETES MELLITUS: NEW HOPE FOR PREVENTION. Robert Dobbins, M.D. Ph.D.
TYPE 2 DIABETES MELLITUS: NEW HOPE FOR PREVENTION Robert Dobbins, M.D. Ph.D. Learning Objectives Recognize current trends in the prevalence of type 2 diabetes. Learn differences between type 1 and type
More informationIntensifying Insulin In Type 2 Diabetes
Intensifying Insulin In Type 2 Diabetes Eric L. Johnson, M.D. Associate Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Assistant
More informationOverview and update of modern type 2 Diabetes philosophy and management. Dr Steve Stanaway Consultant Endocrinologist BCU
Overview and update of modern type 2 Diabetes philosophy and management Dr Steve Stanaway Consultant Endocrinologist BCU Diabetes economics 2009: 2.6M adults with DM in UK (90% type 2) 2025: est. > 4M
More informationDIABETES CARE. Advice. Blood Pressure. Cholesterol. Diabetes control. Eyes. Feet. Guardian Drugs
DIABETES CARE What happens if you follow the Alphabet Strategy? As patients reach their targets, the chances of developing serious complications of diabetes will be reduced! 1 Stroke Eye disease Heart
More informationDiabetes in Primary Care course MCQ Answers 2016
Diabetes in Primary Care course MCQ Answers 2016 Diagnosis of Diabetes HbA1C should not be used as a diagnostic tool in the following situations: (answer each TRUE or FALSE) 1. Gestational Diabetes TRUE
More informationPresented By: Dr. Nadira Husein
Presented By: Dr. Nadira Husein I have no conflict of interest Disclosures I have received honoraria/educational grants from the following: Novo Nordisk, Eli Lilly, sanofi-aventis, Novartis, Astra Zeneca,
More informationFaculty. Program Objectives. Introducing the Problem. Diabetes is a Silent Killer. Minorities at Greater Risk of Having Type 2 Diabetes
Diabetes: The Basics Understanding and Managing Diabetes (Part 1 of 3) Satellite Conference Tuesday, October 18, 2005 2:00-4:00 p.m. (Central Time) Produced by the Alabama Department of Public Health Video
More informationDiabetes and the Elimination of Sliding Scale Insulin. Date: April 30 th 2013. Presenter: Derek Sanders, D.Ph.
Diabetes and the Elimination of Sliding Scale Insulin Date: April 30 th 2013 Presenter: Derek Sanders, D.Ph. Background Information Epidemiology and Risk Factors Diabetes Its Definition and Its Impact
More informationType 2 Diabetes. Management and Medication. HELPLINE: 01604 622837 www.iddtinternational.org
I N D E P E N D E N T D I A B E T E S T R U S T Type 2 Diabetes Management and Medication A charity supporting and listening to people who live with diabetes HELPLINE: 01604 622837 www.iddtinternational.org
More informationUnderstanding diabetes Do the recent trials help?
Understanding diabetes Do the recent trials help? Dr Geoffrey Robb Consultant Physician and Diabetologist CMO RGA UK Services and Partnership Assurance AMUS 25 th March 2010 The security of experience.
More informationUpdates for your practice March, 2013. Vol 2, Issue 14 TLALELETSO. Managing Complicated Diabetes
dates for your practice March, 2013. Vol 2, Issue 14 TLALELETSO Managing Complicated Diabetes Diabetes is increasingly common Managing diabetes and working as part of a multidisciplinary team is essential
More informationType 2 diabetes mellitus
Type 2 diabetes mellitus CLINICAL PRACTICE Management Guidelines for initiating insulin therapy BACKGROUND Insulin is often indicated for patients with suboptimally controlled type 2 diabetes mellitus,
More informationInsulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults
Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults Stock # 45-11647 Revised 10/28/10 Glycemic Goals 1,2 Individualize goal based on patient risk factors A1c 6%
More informationSelf-Monitoring Of Blood Glucose (SMBG)
Self-Monitoring Of Blood Glucose (SMBG) Aim(s) and objective(s) It is important is to ensure that people with Diabetes are given the opportunity to self monitor their blood glucose appropriately as an
More informationTreatment of Type 2 Diabetes
Improving Patient Care through Evidence Treatment of Type 2 Diabetes This information is based on a comprehensive review of the evidence for best practices in the treatment of type 2 diabetes and is sponsored
More informationInitiate Atorvastatin 20mg daily
Type 2 Diabetes Patient Objectives Stopping Smoking BMI > 25 kg m² Control BP to
More informationDiabetes Fundamentals
Diabetes Fundamentals Prevalence of Diabetes in the U.S. Undiagnosed 10.7% of all people 20+ 23.1% of all people 60+ (12.2 million) Slide provided by Roche Diagnostics Sources: ADA, WHO statistics Prevalence
More informationDiabetes Medications: Insulin Therapy
Diabetes Medications: Insulin Therapy Courtesy Univ Texas San Antonio Eric L. Johnson, M.D. Department of Family and Community Medicine Diabetes and Insulin Type 1 Diabetes Autoimmune destruction of beta
More informationDiabetes Subcommittee of PTAC meeting. held 18 June 2008. (minutes for web publishing)
Diabetes Subcommittee of PTAC meeting held 18 June 2008 (minutes for web publishing) Diabetes Subcommittee minutes are published in accordance with the Terms of Reference for the Pharmacology and Therapeutics
More informationType 2 Diabetes - Pros and Cons of Insulin Administration
Do we need alternative routes of insulin administration (inhaled insulin) in Type 2 diabetes? Cons: Suad Efendic Karolinska Institutet, Sweden The Diabetes Management Situation Today Diabetes is a growing
More informationMary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes
Mary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes Objectives Pathophysiology of Diabetes Acute & Chronic Complications Managing acute emergencies Case examples 11/24/2014 UWHealth
More informationInsulin initiation in type 2 diabetes: Experience and insights
Insulin initiation in type 2 diabetes: Experience and insights Joan Everett A diagnosis of type 2 diabetes can be devastating for the individual and their family. Furthermore, many people with diabetes
More informationDiabetes Complications
Managing Diabetes: It s s Not Easy But It s s Worth It Presenter Disclosures W. Lee Ball, Jr., OD, FAAO (1) The following personal financial relationships with commercial interests relevant to this presentation
More informationJill Malcolm, Karen Moir
Evaluation of Fife- DICE: Type 2 diabetes insulin conversion Article points 1. Fife-DICE is an insulin conversion group education programme. 2. People with greater than 7.5% on maximum oral therapy are
More informationInformation for Patients
Information for Patients Guidance for Diabetic Persons having bowel preparation for a flexible sigmoidoscopy or a colonoscopy or a combined gastroscopy and colonoscopy This guidance is provided to assist
More informationThe Early Use of Insulin and Oral Anti diabetic Drugs
The Early Use of Insulin and Oral Anti diabetic Drugs NPS Outreach Pharmacists for Remote Aboriginal Health Services Strategy A remote perspective Dr Hugh Heggie National Medicine Policy To provide timely
More informationThe first injection of insulin was given on
EFFECTIVE USE OF INSULIN THERAPY IN TYPE 2 DIABETES * Bernard Zinman, MDCM ABSTRACT Type 2 diabetes is a progressive disease; an individual s ability to secrete insulin in increasing amounts to overcome
More informationAbdulaziz Al-Subaie. Anfal Al-Shalwi
Abdulaziz Al-Subaie Anfal Al-Shalwi Introduction what is diabetes mellitus? A chronic metabolic disorder characterized by high blood glucose level caused by insulin deficiency and sometimes accompanied
More informationPresent and Future of Insulin Therapy: Research Rationale for New Insulins
Present and Future of Insulin Therapy: Research Rationale for New Insulins Current insulin analogues represent an important advance over human insulins, but clinically important limitations of these agents
More informationA patient s guide to the. management of diabetes at the time of surgery
A patient s guide to the management of diabetes at the time of surgery Diabetes is a common condition, affecting at least 4 to 5% of people in the UK. At least 10% of patients undergoing surgery have diabetes.
More informationINSULIN INITIATION IN TYPE 2 DIABETES IN PRIMARY CARE
INSULIN INITIATION IN TYPE 2 DIABETES IN PRIMARY CARE We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy/procedure
More informationA Guide to Monitoring Blood Glucose for Patients with diabetes in Care Homes
A Guide to Monitoring Blood Glucose for Patients with diabetes in Care Homes 1. Summary... 1 2. Background... 2 3. Purpose 2 4. Responsibilities. 2 5. Blood Glucose Monitoring. 2 6. Resident Groups that
More informationManagement of Diabetes: A Primary Care Perspective. Presentation Outline
Management of Diabetes: A Primary Care Perspective Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine Declaration of full disclosure: No conflict of interest Presentation Outline
More informationManagement of Diabetes in the Elderly. Sylvia Shamanna Internal Medicine (R1)
Management of Diabetes in the Elderly Sylvia Shamanna Internal Medicine (R1) Case 74 year old female with frontal temporal lobe dementia admitted for prolonged delirium and frequent falls (usually in the
More informationA Simplified Approach to Initiating Insulin. 4. Not meeting glycemic goals with oral hypoglycemic agents or
A Simplified Approach to Initiating Insulin When to Start Insulin: 1. Fasting plasma glucose (FPG) levels >250 mg/dl or 2. Glycated hemoglobin (A1C) >10% or 3. Random plasma glucose consistently >300 mg/dl
More informationGuideline for Insulin Therapeutic Review in patients with Type 2 Diabetes
Diabetes Sans Frontières Guideline for Insulin Therapeutic Review in patients with Type 2 Diabetes 1. Introduction This guideline has been developed in order to support practices to undertake insulin therapeutic
More informationLeicestershire Diabetes Guidelines: Insulin Therapy
Endorsed by Leicestershire Medicines Strategy Group Leicestershire Diabetes Guidelines: Insulin Therapy These guidelines are designed for use by those trained and competent in insulin initiation and management
More information嘉 義 長 庚 醫 院 藥 劑 科 Speaker : 翁 玟 雯
The Clinical Efficacy and Safety of Sodium Glucose Cotransporter-2 (SGLT2) Inhibitors in Adults with Type 2 Diabetes Mellitus 嘉 義 長 庚 醫 院 藥 劑 科 Speaker : 翁 玟 雯 Diabetes Mellitus : A group of diseases characterized
More informationADJUSTING INSULIN DOSES CONFLICTS OF INTEREST
ADJUSTING INSULIN DOSES CONFLICTS OF INTEREST Vahid Mahabadi, MD Research grants from Sanofi and Amylin Pharmaceutical Companies Mayer B. Davidson, MD Advisory Board Sanofi Pharmaceutical Company Chief
More informationInsulin Therapy for Optimizing Glycemic Control in Type 2 DM. Puntip Tantiwong Department of Medicine Maharat Nakhon Ratchasima Hospital 22 May 2013
Insulin Therapy for Optimizing Glycemic Control in Type 2 DM Puntip Tantiwong Department of Medicine Maharat Nakhon Ratchasima Hospital 22 May 2013 Case 1 A 45 years-old Thai female with T2DM for 3 years
More informationChallenges in Glycemic Control in Adult and Geriatric Patients. Denyse Gallagher, APRN-BC, CDE Endocrinology Nurse Practitioner
Challenges in Glycemic Control in Adult and Geriatric Patients Denyse Gallagher, APRN-BC, CDE Endocrinology Nurse Practitioner Provide an overview of diabetes prevalence; discuss challenges and barriers
More informationType 2 Diabetes. Tabinda Dugal GP Day 4/05/16
Type 2 Diabetes Tabinda Dugal GP Day 4/05/16 Diabetes Diabetes.a growing health crisis in Britain 869m per year 10% of NHS budget Projections.. 5 million by 2025 Youngest patient? T2DM Type 2 diabetes
More informationComparing Medications for Adults With Type 2 Diabetes Focus of Research for Clinicians
Clinician Research Summary Diabetes Type 2 Diabetes Comparing Medications for Adults With Type 2 Diabetes Focus of Research for Clinicians A systematic review of 166 clinical studies published between
More informationType 2 diabetes Definition
Type 2 diabetes Definition Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes. Causes Diabetes
More informationCauses, incidence, and risk factors
Causes, incidence, and risk factors Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both. To understand diabetes,
More informationPersonalized Therapy Algorithms for Type 2 Diabetes: A Phenotypization-based Approach
Personalized Therapy Algorithms for Type 2 Diabetes: A Phenotypization-based Approach Riccardo Candido on behalf of the Personalized Therapy AMD Study Group Diabetes Canter A.S.S. 1 Triestina, Italy BACKGROUND
More informationInsulin: Breaking Barriers Enhancing Therapies. Jerry Meece, RPh, FACA, CDE jmeece12@cooke.net
Insulin: Breaking Barriers Enhancing Therapies Jerry Meece, RPh, FACA, CDE jmeece12@cooke.net Questions To Address Who are candidates for insulin? When do we start insulin? How do the different types of
More informationPharmacological Glycaemic Control in Type 2 Diabetes
Pharmacological Glycaemic Control in Type 2 Diabetes Aim(s) and Objective(s) This guideline aims to offer advice on the pharmacological management for those who require measures beyond diet and exercise
More informationTreatment Approaches to Diabetes
Treatment Approaches to Diabetes Dr. Sarah Swofford, MD, MSPH & Marilee Bomar, GCNS, CDE Quick Overview Lifestyle Oral meds Injectables not insulin Insulin Summary 1 Lifestyle & DM Getting to the point
More informationInsulin Treatment. J A O Hare. www.3bv.org. Bones, Brains & Blood Vessels
Insulin Treatment J A O Hare www.3bv.org Bones, Brains & Blood Vessels Indications for Insulin Treatment Diabetic Ketoacidosis Diabetics with unstable acute illness ICU Gestational Diabetes: diet failure
More informationInitiation and Adjustment of Insulin Regimens for Type 2 Diabetes
PL Detail-Document #300128 This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2014 Initiation and Adjustment of Insulin Regimens for Type
More informationResident s Guide to Inpatient Diabetes
Resident s Guide to Inpatient Diabetes 1. All patients with diabetes of ANY TYPE, regardless of reason for admission, must have a Hemoglobin A1C documented in the medical record within 24 hours of admission
More informationMany patients with type 2 diabetes will ultimately need
SUPPLEMENT TO JAPI april 2011 VOL. 59 17 Insulin Initiation and Intensification: Insights from New Studies Ajay Kumar 1, Sanjay Kalra 2 Abstract Tight glycemic control is central to reducing the risk of
More informationMy Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started. Combination Therapy
My Doctor Says I Need to Take Diabetes Pills and Insulin... What Do I Do Now? BD Getting Started Combination Therapy How Can Combination Therapy Help My Type 2 Diabetes? When you have type 2 diabetes,
More informationInsulin therapy in type 2 diabetes When and how? Disclosures. Learning Objectives. None relevant to today s talk
Insulin therapy in type 2 diabetes When and how? Cecilia C Low Wang, MD Univ Colorado AMC SOM Department of Medicine Division of Endocrinology, Metabolism, and Diabetes Disclosures None relevant to today
More informationWhat is DIABETES? Gwen Hall Diabetes Specialist Nurse, Community Diabetes Services Portsmouth, Primary Care Team.
What is DIABETES? By: Gwen Hall Diabetes Specialist Nurse, Community Diabetes Services Portsmouth, Primary Care Team. WHAT IS DIABETES? What is diabetes? In simple terms diabetes prevents your body converting
More information